Limited amount and quality of data on medications for treating neuropsychiatric symptoms of dementia

Référence

Huang YY, Teng T, Giovane CD, et al. Pharmacological treatment of neuropsychiatric symptoms of dementia: a network meta-analysis. Age Ageing 2023;52(6):afad091.

Sommaire

These authors searched several databases and registries to identify double-blind randomized trials evaluating at least 2 medications (including placebo) for the management of neuropsychiatric symptoms in adults with dementia. Overall, they included 59 trials with 15,781 participants that evaluated 15 different active treatments. The treatments fell into the following classes: cognitive enhancers, antipsychotics, antidepressants, and mood stabilizers. Most (41%) of the studies enrolled persons with mild-to-moderate dementia; approximately half (52.5%) recruited outpatients; and 6 (10.2%) enrolled nursing home residents. Most studies (86%) were funded by industry. Overall, the risk of bias was high in 12% of the studies, moderate in 61%, and low in 27%. Despite the overall mediocre study quality, the authors chose to pool the data and do a network meta-analysis. The authors reported the main outcomes, various scores for overall improvement and for several neuropsychiatric symptoms, as standardized mean differences (SMDs) where, generally, 0.2 represents a small effect size, 0.5 a medium effect, and 0.8 a large effect size. For overall improvement, risperidone and galantamine were more effective than placebo (SMD -0.20 for each). For reducing aggressive behaviors, the following were statistically significantly more effective than placebo: aripiprazole (SMD -0.31), risperidone (-0.26), divalproex (-0.23), olanzapine (-0.19), and memantine (-0.18). For reducing psychosis, surprisingly, donepezil was the most effective (SMD -0.31), haloperidol was next (-0.27), then aripiprazole (-0.22), and risperidone (-0.15). Patients taking galantamine and rivastigmine were nearly twice as likely as those taking placebo to discontinue treatment for any reason. Drug discontinuation due to adverse effects exceeded placebo for olanzapine (odds ratio [OR] 3.23), divalproex (OR 2.70), galantamine (OR 2.44), rivastigmine (OR 2.27), risperidone (OR 1.75), and donepezil (OR 1.45).